=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649896523
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOLLIE MONTGOMERY, LCSW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2020
-----------------------------------------------------
Last Update Date | 01/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 COURT ST STE 1501
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11242-1115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-927-0698
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 341 EASTERN PKWY APT 5J
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11216-4860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-418-2462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MOLLIE ORIA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 561-418-2462
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------